“You don’t even wash your face, let alone anything else”

Research and Development Grant

Exploring Understandings of the Relationship between Alcohol Misuse, Sexual Health Risk and General Health Outcomes among Scottish Women Offenders.

Introduction

Alcohol misuse or heavy consumption in general is associated with a number of poorer general and sexual health outcomes (including risky sexual behaviour and sexually transmitted infections). Women involved with the criminal justice system have been identified as a highly vulnerable population in terms of health; in addition, alcohol misuse has been found to be significant problem among female offenders, often coexisting with abuse of illicit substances. Despite this, little is currently known about this population’s understanding, or the salience of, the relationship between health and problem drinking. As meeting the health needs of women offenders is likely to be a complex and expensive exercise, it is important that policy makers and practitioners are aware of the extent and nature of these problems and the best way to invest funds and resources. To explore these issues, interviews were conducted with 19 women (reporting previous involvement in the criminal justice system and problematic alcohol and/or drug use) who were attending a community-based rehabilitation centre. Overall, the aim was to provide a more holistic understanding of health and sexual health and their relationship to alcohol (and other substance use) in this vulnerable population.

Key Findings

Initiating Alcohol and Drug Use

Analysis revealed that women perceived their alcohol and drug use as a process underpinned by the increasing experience of disconnection from the self and others, and recovery from addiction as a reversal of this process. Alcohol and drug use in the initial stages was fuelled by the experience of social and emotional isolation with which the use of licit and illicit substances was viewed as an effective means of coping. Substance use was perceived as a way of achieving psychological disconnection from aversive emotions associated with the experience of traumatic events experienced in both childhood and adulthood (i.e. loss and victimisation often occurring in the context of emotionally cold or rejecting relationships). Paradoxically, substance use was also viewed as a way of connecting with others, providing a means of gaining acceptance or intimacy within the relational setting. First drug of choice (i.e. alcohol or illicit drugs) was dependent on availability and normative use within social circles. This noted the initiation of drug use was different from alcohol use in the respect that drug use was often initiated to achieve a sense of connection with a drug using partner.

Continuing Alcohol and Drug Use

Over the longer term, use became increasingly driven by the physical and psychological need for the drug itself as well as the perceived need to cope with the negative social consequences of drug use. Periods of sobriety led to experiences of extreme emotional distress which were aversive and increased the likelihood of a return to substance use. A complicating factor was the persistence for many women of negative life events which was a further disincentive to stop using or drinking.

Given that substance use provided only a temporary solution to emotional distress, attempts to desist were often unsuccessful as the underlying problem remained. In attempt to cope more effectively, women chose to substitute one drug with another. Choice of substitute drug was largely attributed to availability. However, a contributing factor was negative perceptions of the previous drug and a fear of reliving the negative consequences of using that drug. Crucially, whilst substitution of alcohol with illicit drugs (typically heroin) was seen as a progression in the seriousness of use, substitution of illicit drugs with alcohol was not viewed this way. Indeed, alcohol was seen as having other advantages, being viewed as more socially acceptable and convenient, better value for money and importantly, less likely to lead to dependence than illicit drugs.

With growing dependence came increasing disconnection from the self and others as the drug gained centrality in women’s lives. This was especially notable among heavy drinkers who reported increasing self-isolation.

Prolonged use culminated in the experience of total disconnection or ‘hitting bottom’ described as a period during which life ceased to have meaning or value. Reaching this low was viewed as necessary stage in the process triggering conscious recognition that desistence from use was required for survival. Recovery was described as an experience of reconnection wherein the ‘real’ self re-emerged and relationships with others were rebuilt.

Perceptions of Physical Health Risks

In the initial stages of use, women felt personally invulnerable to negative health effects of both drugs and alcohol. While in some cases an awareness of the possible long-term consequences of using or drinking was apparent, women did not view these risks as personally relevant. Rather, the positive benefits of use (in terms of alleviating emotional distress and connecting with others) outweighed concerns regarding possible risks to health.

Whilst some women attributed continued use of substances (in the face of sometimes very serious health threats) to lack of control over their use, others clearly felt that the costs of coping with the extreme emotional consequences of sobriety were a powerful disincentive to desisting. Instead, alcohol and drugs were used as self-medication, i.e. pain management, as health deteriorated.

Medical help only tended to be sought as a last resort or where health conditions were seen as impeding the ability to procure substances (more likely in drug users). For heavy drinkers who tended to self-isolate, help-seeking was especially problematic, as imposed self-isolation brought feelings of security and comfort and contact with others was seen as threatening.

Physical deterioration represented only part of women’s motivation to desist. A key factor appeared to be a growing awareness of the damage done to relationships because of substance use and a wish to repair or renew some of those relationships. This was prompted by a perceived shift in the understanding of a valued relationship. The possibility of gaining, or indeed losing, a relationship that women had come to realise as valuable appeared to be the key factor in decisions to desist.

Recovering physical health was perceived as secondary to achieving mental wellbeing. Increased mental wellbeing in turn facilitated a growing awareness of the value of care of the physical self as the increasing importance of valuing the self was extrapolated to valuing the body.

Understandings of Sexual Health and Risk

The role of alcohol in sexual behaviour and sexual risk behaviour was complex. While participants cited the causal role of alcohol use in risk behaviours (i.e. condom non-use and having sexual intercourse with a number of partners), it was clear that alcohol was also used instrumentally in this context; to facilitate sexual behaviour and, sometimes, sexual risk behaviour. In this sample, reported condom use with non-commercial sex partners was inconsistent.

Calculations of risk in relations to sexual behaviour were based primarily on the perceived ‘safety’ of a sexual partner, and absence of overt signs of ill health. For women who had worked as prostitutes, perceptions of risk were informed by their sex work in a variety of ways, leading to a decreased likelihood of risk reduction practices in personal relationships. It was notable that accurate knowledge about STIs was very low in this sample.

As for physical health, women rarely sought sexual health care and such care was mostly opportunistic. Barriers to seeking care included lack of knowledge and the chaotic lifestyle associated with substance use. In the context of seeking testing for HIV and Hepatitis C, a significant barrier was the perception that this process involved disclosure of past behaviour to a health professional.

Recommendations

The ready availability of low cost alcohol, and the culturally acceptable nature of alcohol consumption appear to be associated with initiation of alcohol use in this vulnerable group. As such, the Scottish Government’s recent emphasis on addressing the low cost and high availability of alcohol as a route to societal change with regards alcohol misuse would appear to be well founded.

According to the findings, continued heavy drinking appears to lead to increasing self-isolation; as such, points of contact with health services are few. Thus, healthcare professionals need to be proactive in offering healthcare opportunistically to these women. In addition, when women do attend healthcare settings, every effort should be made to identify them as problem drinkers and to involve Community Health and Care Partnerships in an effort to meet their multiple needs.

Findings suggest that women perceived that their ability to care for their physical health was compromised by poor mental health. Therefore, efforts to promote physical health are unlikely to be successful in the absence of support for mental health needs over the long term. Indeed, given the interrelated nature of factors underpinning health and substance use risks in this population, no one factor e.g. physical health, sexual health or mental health should be addressed in isolation. A holistic approach is required. Overall, findings are consistent with policies to increase the integration of all services. Efforts to divert women from the criminal justice system to substance abuse treatment in community settings where such a holistic approach is possible (within a safe and non-threatening environment) should be emphasised.

In the process of initiating, continuing and desisting use, physical health is not prioritised among this population. Therefore, health promotion efforts focussing on the negative health effects of alcohol and other substances may not be the best strategy to aid desistence. Given the focus and primary importance of establishing and maintaining relationships as a reason for initiating drug use and re-establishing relationships as a reason for desistence, heath promotion efforts may more usefully targeted at the social and relational consequences of alcohol and other substance use.

Results suggest that risk factors for this population in terms of sexual health do not differ dramatically from other populations, in terms of factors that increase risk (such as risk perceptions and knowledge and the instrumental use of alcohol to facilitate sex). However, the degree to which alcohol is used instrumentally in this population may be higher than in other populations. While this point is certainly speculative, the data does illustrate that there was an association between high levels of sexual victimisation among participants and difficulties with and aversion to sexual intercourse. Discouraging alcohol use in the context of sexual behaviour in this population may require addressing, in the first instance, the sexual difficulties associated with earlier sexual victimisation. Interventions are needed to promote risk reduction practices such as condom negotiation skills. Interventions are also required to improve self-efficacy and promote skills which would allow women to feel secure in both refusing unwanted sexual encounters and communicating their sexual needs to non-commercial partners without the use of alcohol. Finally, given the high rate of reported sexual difficulties among these women, there is may be a need for psychosexual therapeutic intervention with this population.

In the context of seeking testing for HIV and Hepatitis C, a significant barrier was the perception that this process involved disclosure of past behaviour to a health professional. This was perceived as both unrealistic and threatening in the context of these women’s lives. Significant outreach work may be necessary in order to reduce the perceived aversiveness of this process and increase uptake of testing. Training women in this population (who are in recovery and who have undergone testing) as peer educators may be especially useful in allaying fears.